Basic Information
| Provider Information | |||||||||
| NPI: | 1801275490 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILBANKS | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | DEREK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 MADISON ST | ||||||||
| Address2: | STE 600 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981043501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062152004 | ||||||||
| FaxNumber: | 2063426183 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 JEFFERSON PARK AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229033363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349245485 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2015 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD60945817 | WA | Y | Allopathic & Osteopathic Physicians | Ophthalmology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.